In Reply:—

We appreciate the comments and historical perspective regarding the provision of obstetric anesthesia provided by Robert E. Johnstone II, M.D. In his letter, he outlines the pivotal role of his father, Robert E. Johnstone, M.D., as well as contributions from the American College of Obstetricians and Gynecologists (ACOG) in improving obstetric anesthesia services. Beginning in 1981, Johnstone led the ACOG to new standards of care, i.e. , anesthesia provided by anesthesiologists and not by obstetricians. Since that time, surveys have consistently demonstrated dramatic reductions in the number of obstetric anesthetics provided by obstetricians. For example, in 1981, obstetricians performed between 26 and 46% of regional analgesics for labor in all sizes of hospitals.1However, in 2001, obstetricians performed only 1–6% of these procedures.2The most recent Guidelines for Perinatal Care state,

An obstetrician may administer the anesthesia if granted privileges for these procedures. However, having an anesthesiologist or anesthetist provide this care permits the obstetrician to give undivided attention to the delivery. If obstetric anesthesia is provided by obstetricians, the director of anesthesia services should participate with a representative of the obstetric department in the formulation of procedures designed to ensure the uniform quality of anesthesia services throughout the hospital.3 

In addition to these changes that were fundamental to improving patient safety, leaders within the American Society of Anesthesiologists (ASA) have also been instrumental in establishing guidelines and practice parameters to continue these efforts. The ASA published one of the first documents in 1988. Although not guaranteed to provide a specific outcome, the Guidelines for Regional Anesthesia in Obstetrics were designed to provide anesthesia care providers with a framework that allowed them to interpret and establish guidelines for their own practices.* Other efforts to encourage quality patient care have included publication of Practice Guidelines for Obstetrical Anesthesia in 1999.4Although these evidence-based, systematically developed recommendations were not intended to serve as standards or absolute requirements, they provide basic recommendations to assist practitioners in decision making. More recently, Optimal Goals for Anesthesia Care in Obstetrics, a joint statement by the ASA and ACOG, was published to further emphasize the importance of collaborative efforts by anesthesiologists and obstetricians in the provision of safe and most effective care for obstetric patients.†

Despite many advancements in the practice of obstetric anesthesia, there has been debate within the specialty resulting from denial of payment for regional labor analgesia by third-party payers.2In these cases, reimbursement was denied because of a lack of “medical indication.” In response, the ASA and ACOG issued a Statement on Pain Relief during Labor in 2000 with revision in 2004.5According to this statement,

Labor results in severe pain for many women. There is no circumstance where it is considered acceptable for a person to experience untreated severe pain, amenable to safe intervention, while under a physician’s care. It is the position of ACOG and ASA that third-party payers who provide reimbursement for obstetric services should not deny reimbursement for regional analgesia/anesthesia because of an absence of other “medical indications.”

Johnstone has provided interesting historical information about early efforts by the ACOG to improve patient safety and care. Since that time, a number of substantial changes have occurred in the practice of obstetric anesthesia, as evidenced by data from the 1981, 1992, and 2001 workforce surveys.1,2,6The most recent survey suggested that more parturients used some type of analgesia for labor than ever before and that regional anesthesia for cesarean delivery is the preferred technique. Despite controversy and continued economic pressure, more anesthesiologists are actively involved in the practice of obstetric anesthesiology and continue to strive for safe and effective care of obstetric patients.

‡University of Colorado School of Medicine, Denver, Colorado.


Gibbs CP, Krischer J, Peckham BM, Sharp H, Kirschbaum TH: Obstetric anesthesia: A national survey. Anesthesiology 1986; 65:298–306
Bucklin BA, Hawkins JL, Anderson JR, Ullrich FA: Obstetric anesthesia workforce survey: Twenty-year update. Anesthesiology 2005; 103:645–53
American Academy of Pediatrics and American College of Obstetricians and Gynecologists: Guidelines for Perinatal Care, 5th edition. Elk Grove Village, Illinois; Washington, D.C., American Academy of Pediatrics and American College of Obstetricians and Gynecologists, 2002, p 140
Elk Grove Village, Illinois; Washington, D.C.
American Academy of Pediatrics and American College of Obstetricians and Gynecologists
Practice guidelines for obstetrical anesthesia: A report by the American Society of Anesthesiologists Task Force on Obstetrical Anesthesia. Anesthesiology 1999; 90:600–11
American College of Obstetricians and Gynecologists Committee Opinion #295: Pain relief during labor. Obstet Gynecol 2004; 104:213
Hawkins JL, Gibbs CP, Orleans M, Martin-Salvaj G, Beaty B: Obstetric anesthesia work force survey, 1981 versus  1992. Anesthesiology 1997; 87:135–43